EVA LUA TING WRA PA ROUND IN DETROIT, WA YNE COUNTYJ. Bayley Zito, PhD1; Monica Hampton, LMSW2 ; Jasmine Boatwright3

1The Guidance Center, 2Detroit Wayne Mental Heal th Authority, 3Development Centers

A 25-question fidelity survey developed by Michigan State University and endorsed by the Michigan Department of Health and Human Services was used to evaluate fidelity based on the 10 principles of WA.

Statements in the fidelity survey were grouped based on which of the 10 WA principles they represented (no statements specifically addressed team-based). Each principle was then given a grade out of 100.

Scoring: For this summary N/A' or 'I don't know' responses were excluded. Scores were calculated by first re-coding the Likert items to scores out of 100 (Yes=100,More Yes than No=75,Neutral=50,More No than Yes=25,No=0). The average score across principles was then calculated for each person (e.g.?culturally competent is the average of responses to questions 8 and 9?). Finally, the average for all participants was calculated.

FIGURE 2 : Overall, youth gave more variable ratings and were less satisfied with WA than their caregivers.

Wraparound is a process based on general principles and tailored to families. This makes monitoring the effectiveness of Wraparound uniquely challenging as implementation can vary widely (Walker et. al, 2003). This challenge is further exasperated by the evidence that Wraparound is only effective when provided with high fidelity (Bruns, 2008). Peer reviewed work finding successful improvement of outcomes most often comes from small projects with a high degree of oversight, training and supervision (Bruns, 2008). The Detroit Wayne Mental Health Authority (DWMHA) provides WA services to over 500 families annually, through 11 Community Mental Health Contract Providers.

In the past, measures of fidelity in Wayne County focused solely on facilitator performance. An important component missing from these evaluations was youth and parent voice. Connections Wayne County System of Care (SOC) conducted focus groups in order to identify areas of excellence and need for growth as described by families receiving Wrapround services.

M OTIVA TION FOR RESEA RCH

DISCUSSION

A CK NOWLEDGEM ENTS

All 11 Contract Providers and the families they serve were invited to participate in the focus groups. Families were recruited via phone call and asked to bring the youth receiving services and a caregiver who is part of the WA team. Families who attended answered questions developed with the 10 principles of WA in mind:

M ETHODOLOGY

- Family voice and choice - Team-based- Natural supports- Collaboration- Community-based

- Culturally competent- Individualized- Strengths-based- Persistence - Outcome-based

5 focus groups took place during August and September 2015.

- Focus groups ran approximately 2 hrs:- Introduction and consent (30 mins)- Taped discussion (1 hour)- Fidelity survey and incentive (30 mins)

Following the introduction, caregivers and youth had separate discussions led by a peer facilitator. Caregiver discussions were led by Parent Support Partners from Family Alliance for Change; the youth discussion was lead by members from Youth United, a youth-led organization.

The final sample included 28 caregivers and 23 youth from 9 Contract Providers. - Time spent in WA ranged from 1 to 36 months

(average: 15.33 months)- Children/youth ages ranged from 7 to 18 years

(average: 12.56 years)- 4 families had already graduated WA

FOCUS GROUP OUTCOM ES-CHILDREN/YOUTH

FOCUS GROUP OUTCOM ES-CA REGIVERS

Children and youth had a less structured discussion. They were asked to describe what they thought was positive about WA, what they would like to change and to come up with any suggestions for how to make WA better.

TABLE 3

Outcome Matrix

Posit ive Outcomes/Resources

Fel t Supported By Facil i tator

Had Own Voice

Not Feel ing Respected

Meet ings Meet ings

Team Team

Did Not Have Own Voice

Posit ive Outcomes/Resources

TABLE 1

SURVEY RESULTS

Special thanks to the members of Youth United and the Parent Support Partners from Family Alliance for Change for helping to facilitate the focus groups. In particular, thank you to Tyanna McClain, Sheryl Calloway, Deborah Martinez and Barbara McCowin helping this project succeed.

We would also like to acknowledge the organizations that graciously allowed us to use their space, Phoenix Academy, The Guidance Center, Lincoln Behavioral Services, The Northeast Guidance Center and Hegira.

Caregiver outcomes: The survey grades map well onto the focus group discussion outcomes. Caregivers scored community-based and natural supports the lowest. During discussion it was clear that the support of friends and family as well as community resources were the things most lacking for families at all stages of WA.

The original tool measuring facilitator competency and understanding also consistently showed lower scores in the transition phase of Wraparound. Additional training in this area could better prepare families for life after Wraparound and lessen feelings of abandonment.

Youth outcomes: Focus group discussion and survey data both showed caregivers feeling more satisfied with Wraparound than youth. However, youth consistently described at least some positive experiences with WA at each site. Despite this, youth were least likely to agree with statements relating to the principle outcome-based in the fidelity survey. Research has shown that youth value autonomy, confidentiality and an age- appropriate environment when receiving care (Ambresin et. al, 2012). Feeling a lack of respect, mistrust of the facilitator and distaste for the format of meetings could lead youth to feeling less satisfied with services and less willing to continue services even when outcomes are improving.

Data Driven Decisions Based on the discussions that occurred throughout the community in response to these results, it was determined the following changes would occur:

To help support youth voice

- A member of Youth United will become part of the Wayne County Wraparound Project Team (in progress)- Youth peers will be made available to the Wraparound teams, similar to Parent Support Partners (in progress)

- In FY16-17 Youth Peer Support Services became Medicaid billable. The SOC is supporting agencies as they go through the process to hire and train Youth Peers

To help improve caregivers stated feelings of abandonment

- Trainings will be developed to help facilitators build skills around keeping appropriate boundaries and improving the transitioning phase (Complete: Training occurred July FY15.16)

- Supervision with Wraparound supervisors will now include a focus on appropriate boundaries with the family (Complete and ongoing) - The Supervisor shadowing tool will be revised to better assist with fidelity monitoring (in progress)

ReferencesAmbresin A,Bennett K,Patton G,Sanci L,Sawyer S (2013). Assessment of youth-friendly health care: A systematic review of indicators drawn from young peoples perspectives. J Adolescent Heal th, 52:670?681.

Bruns,E. (2008).Measuring wraparound f idelity. In E. J.Bruns & J.S.Walker (Eds.),The resource guide to wraparound. Port land, OR: Nat ional Wraparound Init iat ive, Research and Training Center for Family Support and Children's Mental Heal th.

Walker, J. S., & Schutte, K. (2003). Individualized service/support planning and wraparound: practice-oriented resources. Port land: Port land State University, Research and Training Center on Family Support and Children's Mental Heal th

Contact : Bayley Zito (bzito@iamtgc.net)

TABLE2

- "Helped me learn how to overcome obstacles."

- "[Facilitator] asked personal questions, then told my mom."

- Youth always felt like they were in the 'hot seat' during meetings

- Youth didn't feel like they had a voice selecting team members

- Facilitator helped youth get a job

- Facilitator is like family- Facilitator would have

loud conversations with parents, others could hear

- Youth didn't feel comfortable in own home

- Youth didn't get to pick who was on the team

- Facilitator didn't listen to youth, would always side with parent

- "Learned that not everyone is against you or wants something from you"

- "They helped me stay organized and focused"

- Youth didn't feel like they could trust facilitator, they would share information back with Mom and youth would get in trouble

- Youth never felt that they had a chance to share their side

- Youth got advice and help when needed

- Youth was allowed to develop their own goals

- Youth was not notified of meeting ahead of time

- Meetings were too early

- Youth learned anger management skills

- Talking with the facilitator one-on-one was nice

- Youth did not like meeting times

- Parent refused to add friends or family to team because they 'didn't want anyone in their business'

Youth Feedback

OVERARCHING THEMES

FIGURE 1

PRAIS

E FOR TH

E

WA FA

CILITA

TOR

RESOURCE AVAILABILITY

CHALLENGES WITH

TRANSITIONING

LACK OF NATURAL

SUPPORTS

POSITIVE FAMILY

OUTCOMES

- "When things start going good, don't just drift off."

- "I wish we had learned the skills to keep the same behaviors when the WA was over."

- "I was kind of mad when she [WA facilitator] kicked us out. I'm like, 'are you serious' I was kind of hurt.

- "The ending process needs more, something is missing."

- "Sometimes I feel as though my team doesn't have my back, but I know my facilitator does."

- "She [WA facilitator] even looked up how my religion celebrates holidays."

- "My facilitator is like extended family."- "She [WA facilitator] was more focused

on the individuals of our family and what our needs were. It wasn't like 'I'm going by the book,' it was really felt individualized."

- "I don't have anyone that's available [to be on the team]. My husband is in the home, but he doesn't participate in the meetings."

- "His dad, my husband and other people left the team because my child treated them bad."

- "My father was on the team last time. But he passed away last year." Family returned to WA following passing. - "We had to do food pantry and stuff like that, she [WA facilitator] set us up with

that."- "Flyer to different programs, but my child doesn't get involved in anything."- "Not too many resources in my neighborhood."

- "My son is more calm now. I couldn't take him out by myself and now I can."

- "Before WA something happened that kind of tore my family apart and now we are all coming back together."

- "We like each other now!"- "My son opens up more to speak, to

say what's wrong with him or if he's feeling down."